Bisphosphonates May Be Underprescribed in Corticosteroid Users

People with chronic skin diseases who take oral corticosteroids
long-term may be at increased risk for bone-loss-related problems,
according to a study showing that doctors do not always adequately
address the risk of bone loss in this patient population.

The study by Liu and colleagues was published in the Archives
of Dermatology and
reported by MedPage Today on January 16, 2006.

At one dermatology center, 80% of people receiving
corticosteroid therapy for dermatological disease were not taking
bisphosphonates, thereby raising their risk of bone fractures and
osteoporosis, said Victoria P
Werth of the University of Pennsylvania, according to MedPage
Today.

Clinical Trial

The cross-sectional study included 35 men and women who had
chronic skin disease for which they were taking prednisone (10 mg/day or more) or an
equivalent drug. Participants were in their mid-50s, mostly white
and had been taking prednisone for 17 months on average.

Of the 35 participants, 28 (80%) were taking no bisphosphonate
prior to their referral. Bone mineral density scans for 18
participants showed that seven had normal bone mineral density,
eight were osteopenic and three were osteoporotic.

The results agreed with those of previous studies, which
suggested that most people who receive long-term glucocorticoid
therapy have low bone mineral density and that more than 25% suffer
bone fractures. In these people, the greatest loss of bone mass
occurs during the first six months of corticosteroid therapy, and
the risk of fracture increases greatly within the first three
months.

Guidelines for Bisphosphonates

The American College of Rheumatology (ACR) guidelines were
updated in 2001 to recommend that doctors prescribe bisphosphonate
therapy for all patients receiving long-term prednisone (5 mg/d or
more), according to MedPage Today. However, equivalent guidelines
do not exist for dermatologists.

The authors wrote, "our study demonstrated a dramatic underuse
of bisphosphonates by our referral physicians, which was not
influenced by the publication of the ACR guidelines."

They recommended that, "Unless there is a specific
contraindication, bisphosphonates should be prescribed
concomitantly with the initiation of corticosteroid therapy in
diseases for which long-term glucocorticoid use is anticipated as
part of the standard care."

The two FDA-approved bisphosphonates used to treat
glucocorticoid-induced osteoporosis are Merck's Fosamax (alendronate) and Procter &
Gamble's Actonel (risedronate), both of
which are available in a once-weekly oral formulation.

The researchers also noted that patients should undergo a
baseline bone mineral density assessment, as well as taking calcium
and vitamin D supplements, although the evidence that they help to
prevent fractures is mixed. Although generally well tolerated,
bisphosphonates should be used with caution in pre-menopausal
women, as the drugs increase the risk of fetal skeletal
abnormalities, according to the researchers.

The study was supported by grants from the National Institutes
of Health and Procter & Gamble.